Impact of the implementation of Chronic Care Model for diabetes in Tuscany

1. Impact of the implementation of Chronic Care Model for diabetes in Tuscany Valentina Barletta Epidemiology Observatory – Regional Health Agency of Tuscany, Italy

2. Italy has a tax-based, universal coverage national health system organized in three levels: national, regional, local • The Tuscan Healthcare System: some data • 3,7 millions inhabitants • 17 Public Health Authorities: • 12 Local Health Authorities and 5 Teaching Hospitals • organized in three Network “Area Vasta”: • North West Area Vasta: 2 T.H. and 5 L.H.A. • Center Area Vasta: 2 T.H. and 4 L.H.A. • South East Area Vasta: 1 T.H. and 3 L.H.A. • 2.940 GPs (1200 patients on the average) [2009]

3. The Aging Population Population >64 years - Tuscany 23,3% - Italy 19,9% Epidemiology of Chronic Diseases in Tuscany Number of diagnosed cases for each of the 5 “CCM chronic diseases” per 1,000 residents 16 + according to administrative data; hypertension limited to exempted cases (MaCro system) Tuscany Population Pyramid 2005 2025

4. From traditional healthcare to proactive healthcare Where Tuscany wants to invest? Proactive healthcare: The patient’s needs are taken into account before the disease worsening and possibly before disease onset, getting better health conditions for the population, addressing equity issue too. Traditional healthcare: The healthcare system acts only when the chronic patient worsens becoming acute. Chronic diseases are not well treated and prevention as well as risk factors are not taken into account. Health inequities are not taken into account The healthcare system is able to manage chronic diseases and to be effective in facing the acute diseases onset.

5. Which model to drive the change: the Expanded Chronic Care Model (CCM) Expanded Chronic Care Model: • main strategy of the Regional Health Plan • new delivery System design focused on multi-professional care team • new role of nurses in self management support; • decision support through shared clinical pathways; • investment on integrated information system • community resources exploitation • Focus on prevention and health determinants (community oriented primary care)

6. GPs and other health professionals operators (nurses, medical assistant …) organized in practice (6-15 GPs) to care for chronic patients with a proactive approach (Chronic Care Model) 11 LHAs • 56 practice • 497 GPs • 112 Nurses • 618.969 Patients Pilot phase June 2010 Other groups are expected to be involved • 31 practice • 301 GPs • 62 Nurses • 337.213 Patients Extention phase March 2011 6

7. Study objectives To evaluate the effect of the CCM-based program being implemented in Tuscany on a) quality of care in terms of process indicators b) per capita health care costs in patients with diabetes

8. Study design A controlled before – after study Groups and observation periods (data available up to 31/12/2011): Pilot phase starting point 1/7/2010 2009 2011 CCM - GPs patients No CCM - GPs patients Process indicators & Care cost per capita for selected services Prevalents at 1.1.11 Prevalents at 1.1.09

9. Data sources Data sources: the Tuscan longitudinal record-linkage system “MaCro” (Chronic Diseases)* of inhabitants registry, exemptions, specialist care, drug dispensing and hospital discharge records (administrative data) through which: cohorts of residents with specific diseases can be identified and • levels of adherence to clinical recommendations can be calculated * Gini R et al. Chronic disease prevalence from Italian administrative databases in the VALORE project: a validation through comparison of population estimates with general practice databases and national survey (sumbitted for publication)

10. CCM: 33 No CCM:125 Diabetic patients (2011) GPs • CCM 24.560 • No CCM 68.807 • CCM 351 • No CCM 1330 CCM: 146 No CCM:653 CCM: 32 No CCM:167 CCM: 62 No CCM:224 CCM: 78 No CCM:161 Age (68% over 65), gender, and Charlson index distribution of the groups are quite similar

11. Glycated haemoglobin Total serum cholesterol

12. creatinine microalbuminuria eye examination

13. ACE inhibitors aspirin statins

14. Care cost per capita for selected services (to update) Laboratory testing Diabetes specialist assessment

15. Guidelines Composite Indicator (GCI) (annual assessment of A1C and at least two assesments from among eye examinations, total serum cholesterol, and microalbuminuria)* • In 2009 GCI was positive for the 33% of patients (35% for patients assisted by GPs who were going to adhere to CCM the following year) • In 2011 GCI was positive for the 39% of patients (48% for patients assistend by CCM - GPs) • At a multilevel analysis, the average variation of GCI, in a given district, was: • 1,4 for no CCM - GPs • 11,1 for CCM - GPs *Giorda C et al.- The Impact of Adherence to Screening Guidelines and of Diabetes Clinics Referral on Morbidity and Mortality in Diabetes. PLoS ONE, April 2012

16. Multivariated model Differences are observed between CCM and no-CCM GPs within the same district

17. Summarizing… In patients with diabetes enrolled with CCM-GPs, compared with patients with diabetes enrolled with no-CCM-GPs: Quality of care in terms of process indicators has improved (evidence based monitoring !) The percentage of patients treated with specific drugs does not change (therapeutic inertia* ?) Per capita cost of diabetes specialist care has decreased Per capita cost of laboratory testing has increased * "Therapeutic inertia" is usually defined as the failure to change or uptitrate treatment strategy when a disease is uncontrolled. In patients with type 2 diabetes, this may occur with antidiabetes treatments and/or treatment for various cardiovascular risk factors

18. Thank you for your attention! valentina.barletta@ars.toscana.it